# Situation: A 26-year-old man with an incomplete spinal cord injury at the fourth thoracic (T4) level from a fall 4 months ago is on a rehabilitation unit. He has an indwelling urinary catheter until his bladder program starts. He has not taken sildenafil or any other phosphodiesterase-5 inhibitor. He suddenly reports a pounding headache. His blood pressure (BP) is 184/100 mmHg (usual 104/64 mmHg), and his heart rate is 52/min. He is lying flat, and his urine bag has barely filled in 3 hours. The physician has ordered nitroglycerin paste if systolic BP stays at or above 150 mmHg after the bladder is managed; assume that it does. In what order should the nurse act? 1. Loosen his clothing and the leg-bag straps 2. Apply the ordered nitroglycerin paste above the injury level 3. Sit him upright with his legs lowered 4. Check the catheter tubing for kinks and irrigate it if blocked

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=630528  
> language: ko  
> subject: Nursing Practice IV — Care of Clients with Problems in Nutrition and Gastrointestinal, Metabolism and Endocrine, Perception and Coordination

## 문제

Situation: A 26-year-old man with an incomplete spinal cord injury at the fourth thoracic (T4) level from a fall 4 months ago is on a rehabilitation unit. He has an indwelling urinary catheter until his bladder program starts. He has not taken sildenafil or any other phosphodiesterase-5 inhibitor.

He suddenly reports a pounding headache. His blood pressure (BP) is 184/100 mmHg (usual 104/64 mmHg), and his heart rate is 52/min. He is lying flat, and his urine bag has barely filled in 3 hours. The physician has ordered nitroglycerin paste if systolic BP stays at or above 150 mmHg after the bladder is managed; assume that it does. In what order should the nurse act?
1. Loosen his clothing and the leg-bag straps
2. Apply the ordered nitroglycerin paste above the injury level
3. Sit him upright with his legs lowered
4. Check the catheter tubing for kinks and irrigate it if blocked

## 보기

1. 3, 4, 1, 2
2. 1, 3, 4, 2
3. 3, 1, 4, 2 **✔ 정답**
4. 4, 3, 1, 2

**정답: 3**

## 해설

Sitting upright with the legs lowered lowers blood pressure at once through orthostatic pooling, and loosening clothing and straps removes easy triggers. The bladder is the most common trigger, so the catheter is checked and cleared next. If systolic pressure stays at or above 150 mmHg after the bladder is managed, the ordered fast-acting antihypertensive is given before the bowel is checked.

## 심화 해설

Recognizing autonomic dysreflexia
A client with a spinal cord injury at T6 or above who develops a sudden pounding headache, a blood pressure far above his usual (184/100 mmHg versus 104/64 mmHg), and a slow heart rate (52/min) is having autonomic dysreflexia. A noxious stimulus below the injury triggers a massive sympathetic response that constricts blood vessels below the level. The brain senses the hypertension and slows the heart through the vagus nerve, but it cannot send signals down past the injury to relax the vessels. The rise in pressure can cause stroke, seizures, or death, so it is an emergency. His nearly empty urine bag over 3 hours points to the most common trigger: a blocked catheter and distended bladder.

The correct sequence: 3, 1, 4, 2
Sit him upright with the legs lowered first, because this lowers blood pressure at once by pooling blood in the legs. Then loosen clothing and leg-bag straps, which removes quick, easy triggers and takes only seconds. Next, check the catheter tubing for kinks and irrigate it if blocked, because the bladder is the most common cause and emptying it often ends the episode. Only if systolic pressure stays at or above 150 mmHg after the bladder is managed does the nurse apply the ordered nitroglycerin paste above the injury level. The stem tells you to assume the pressure stays high, so the drug comes last.

| Step | Action | Why at this point |
| --- | --- | --- |
| 1st | Sit upright, legs lowered | Immediate drop in blood pressure |
| 2nd | Loosen clothing and straps | Fast removal of simple triggers |
| 3rd | Check and clear the catheter | Most common cause |
| 4th | Nitroglycerin paste if systolic stays ≥150 mmHg | Drug only after the cause is addressed |

Why the other orders are wrong
Any sequence that begins with checking the catheter or loosening clothing delays the single fastest way to lower pressure, which is sitting the client up. Starting with loosening clothing while he is still lying flat leaves the pressure high longer. The drug never comes first because removing the trigger often resolves the episode, and the order is written for pressure that persists after the bladder is managed. The stem also notes that he has not taken a phosphodiesterase-5 inhibitor; this matters because nitrates are contraindicated with those drugs.

After the bladder
If the bladder is not the cause or pressure stays high, the nurse checks the bowel for impaction, using lidocaine gel before rectal examination. Blood pressure is monitored every few minutes, the episode and its trigger are documented, and the client and family are taught to recognize and manage future episodes.

Exam takeaway
Key point Autonomic dysreflexia: sit up first, remove triggers, check the bladder, then the bowel, and use ordered antihypertensives if pressure stays high.

## 임상 시나리오

Autonomic Dysreflexia ResponseInjury at T6 or above
Sudden pounding headache, blood pressure of 184/100 mmHg against a usual 104/64 mmHg, and bradycardia signal autonomic dysreflexia, an emergency triggered by a stimulus below the injury.

First sit him upright with legs lowered, then loosen clothing and straps, then check and clear the catheter, the most common trigger.

If systolic stays at or above 150 mmHg after the bladder is managed, apply the ordered nitroglycerin paste, then check the bowel with lidocaine gel.

CautionDo not leave him lying flat while searching for the cause. Nitrates are contraindicated if a phosphodiesterase-5 inhibitor has been taken.

## 핵심 개념

- **Autonomic dysreflexia** — A dangerous rise in blood pressure in spinal cord injury at T6 or above, triggered by a stimulus below the injury.
- **Bradycardia** — A heart rate below 60/min; here a reflex response to the sudden hypertension.
- **Noxious stimulus** — An irritating input such as a full bladder, impacted stool, or tight clothing that can trigger dysreflexia.
- **Phosphodiesterase-5 inhibitor** — A drug such as sildenafil; combining it with nitrates can cause severe hypotension.

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